Dom in South Africa: Almost Over

I'm going to miss this view.

One of the four preterm (2 twins) babies that I delivered last week.
This one is shaking my hand after a particular rough ride.

HIV is just the most ghastly epidemic. One would think that maybe I’d have become used to its woes by now, but no – everything is more acute; it makes me question my own mortality far more than I ever have. Each day I encounter at least one devastating case of a young girl or boy; someone who should be full of energy and exploring who they are, completely crippled. I am always amazed by how much people age. Just the other day I saw two girls, one 19 and the other 21. Both looked well into their 40’s, and very sick forty year olds at that. Their eyes were full of despair and absolute exhaustion. I try to stop myself thinking too much about each case, but sometimes my mind drifts, and it is easy to do so. As I sit there, while the nurse translates the history, I find myself looking at the young person before me and think: that could be me; it could be any of us. We all know that condoms are very effective at preventing the spread of HIV, but how many times have you decided not to use one? To start with, you need to have them freely available. Anyway, this isn’t about my sexploitations, but about the ease as to which this virus can be spread and how easy, in theory, it could be to stop. I’ve just finished a book entitled: “The Wisdom of Whores,” by Elizabeth Pisani. It is an extremely well written piece, deeply moving, but often light-hearted, analysis of HIV and all the demons that surround it.

***

I am now halfway into my last ever weekend of work at Holy Cross Hospital. As I mentioned, last Friday, Saturday and Sunday I was the boss. It turned out to be a really quiet shift in casualty: no stabs, no sick babies, no bleeding orifices - all in all, very good. However, maternity was a different story. I ended up performing six caesarean sections. The privilege that we as doctors, midwives and nurses have of being involved in child birth really is special, and I cannot help but smile each time I coax a baby from its mother’s womb. However, I shall be honest: I will be quite happy if I do not have to do any more C-sections ever again. They can be a nerve racking affair, especially when the uterus bleeds, and boy does it bleed. Although, as of yet I haven’t had any problems stopping the bleeding, even when I severed the uterine artery on one occasion a few months back. The main reason I don’t fancy doing more of these procedures is because I am grossly under-qualified. This shouldn’t be how a healthcare service is run, but without my dubious skills over the weekend, the mothers would have had to make a long journey to our sister hospital. Without money or transport, this can be impossible and the ambulance service, as I have said before, is useless at the best of times. So, that is why I do cut: there isn’t really another option, and so far nothing has gone wrong. I take my time, think about my next move and try not to slice anything but the uterus.

Blood stained trousers after a busy weekend.
Good thing I always wear my trauma goggles.

So, I said last weekend was rather quiet in casualty (it should have been busy – it was pay day); last night was a very different story. I feel as if the community know it’s my last weekend, so they are throwing me as many assaults as they can. As morbid as it sounds, I really enjoyed the trauma I encountered last night. There is often a sense of instant gratification as you can literally save lives there and then. Within the space of an hour a young man had been brought in with multiple gunshot wounds – at this point I was busy performing an assisted delivery with a ventousse (vacuum) on a stubborn baby who came out very flat. I received the call just as the little one popped out. I ran the new born to the resuscitation room, kick started him into breathing and then left the midwives to kindly clear up the mess I had made (my blood stained trousers are evidence of this) and repair the episiotomy I made. When I arrived in casualty, the man was on oxygen (this still impresses me – last year it would take 30 minutes to find an oxygen mask), the sisters were putting in two large IV lines and…… oh, he wasn’t breathing: he was dead. There really was little I could do (this is the point when I don’t enjoy my job and there is no such instant gratification that I just described). He had been scatter bombed with bullets. I’m no ballistics expert, but this is how I think someone must look if they were shot at with an Uzi. His entire family were there watching. For a second I entertained the idea of cardiorespiratory resuscitation, however, there was another very sick gentleman in the next gurney who had a chance of life and there was only one doctor, myself. I had to move on.

The latest fashion at Holy Cross

The second patient had been stabbed in the chest. The first thing I noted was how pale he looked. His pulse was weak and slow, his neck was engorged and I couldn’t hear any breath sounds on one side of his chest. I thought to myself, could this be a tension pneumothorax? This is when air gets trapped and sucked in between the lung and rib cage. With each breath, the volume and pressure of air increases and eventually squeezes the heart until it stops. What I should have done is listen to my gut and shove a needle into the front of his chest, subsequently hearing the satisfying hiss as the pressure releases (a very heroic manoeuvre – you see it in the movies, often with a BIC biro). However, I didn’t do this. Why? I don’t know, but partly because the chest-drain kit was already there and I had a tube in his thorax within 30 seconds. As the whoosh of air, and some blood, came out of the drain the young man instantly perked up. This was definitely one of those moments I mentioned earlier – a few more minutes and he would have been in the same situation as my first patient: dead. The young guy, and his mother for that matter, was extremely grateful and he promised me he would keep out of fights in the future. I wonder if he’ll keep his word. Just as I thought the evening, well morning – it was 2am – couldn’t get more exciting another curve ball was thrown.

A man in his thirties had three small stab wounds on his chest. His breathing was fine and there was no evidence of air or blood in the thorax like the previous fella. However, one of the stab wounds was sitting right over his heart. I did a scan and saw a large sac of fluid encasing the four chambers that pump blood around the body: he had a stab heart and the fluid around it was blood. Fortunately, he was relatively stable and seeing as he was still alive 2 hours after the incident, he had a pretty good prognosis. I did a pericardiocentesis to confirm my findings. This is when one shoves a massive needle, under ultrasound guidance, into the pocket of fluid. A relatively hairy procedure as you can imagine: too deep and you may end up puncturing a ventricle and making the situation a lot worse. First time was the charm and I aspirated 20mls of dark red blood – a good sign. If it was bright red, it would probably mean there was still bleeding, or that I just punctured the heart: not so good. I observed him for an hour, to make sure the fluid wasn’t building up and squeezing his cardiac apparatus, much like in a tension pneumothorax, and then sent him to the surgeons at our referral unit.

The weekend is almost over now and my time at Holy Cross is coming to an end. I really am going to miss this place.